The value of community health workers (CHWs) in connecting people to local resources and clinicians became increasingly apparent to health system and public health leaders during the pandemic.
“We saw how they were an antidote to misinformation and mistrust during our COVID-19 vaccination campaign in New York City,” said Dave A. Chokshi, M.D., M.S.c. “It’s one of the investments I’m proudest of from my tenure as the city’s health commissioner, when we launched a program known as the Public Health Corps to advance CHWs.”
The number of CHWs has grown to approximately 80,000 across the United States today. But some advocates maintain that a much broader and systemic deployment of CHWs with more adequate funding could have a much greater impact.
Organizational leaders addressing social determinants of health are trying to figure out what the next policy-making steps should be in solidifying the CHW role and developing best practices for workforce development, reimbursement and data sharing.
Shreya Kangovi, M.D., CEO of IMPaCT Care, which helps organizations build and manage their CHW workforces, thinks we should first step back and look at how we spend $4.5 trillion on healthcare in the United States. Thirty percent of that goes to hospital care; another 20% goes to doctors, and the other 50% goes to other clinical care, like drugs and devices, she estimated.
“We don’t really know how much goes to address the social determinants of health, but it’s often an unmeasured afterthought,” said Kangovi, who is also a professor at the University of Pennsylvania School of Medicine. “The way that we spend is inversely related to the value of our healthcare dollar. We know that clinical care is dwarfed by social, behavioral and economic factors, yet we are wildly out of sync with how we’re spending our money and with the workforce. We cannot right the ship of value in the next era of American healthcare without radically rethinking our workforce.”
Chokshi and Kangovi were speaking in December at a meeting of a group called the Common Health Coalition, which was officially launched in March 2024 to turn the lessons of the pandemic response into actionable strategies to strengthen the partnership between healthcare and public health systems. Founding members include AHIP, the Alliance of Community Health Plans, the American Hospital Association, the American Medical Association, and Kaiser Permanente, but the organization has since grown to almost 100 members.
One of the coalition’s first efforts, launched in December 2024, is the Common Health Challenge on Community Health Workers, designed to advance meaningful CHW initiatives across the country through partnerships between healthcare and public health. The coalition seeks to offer guidance about how to better integrate community health workers into their organizational efforts.
Trust is key
The key word in thinking about CHWs is trust, Chokshi stressed. “CHWs are trusted professionals who build bridges among clinical, public health and community organizations to facilitate access to services and improve health. In my own clinical practice, I see each week how community health workers fill in the gaps of our system, gaps in understanding, gaps in services and gaps in trust. I think of how one of the CHWs I worked with called almost a dozen pharmacies near one of our patients to figure out which would be best for him, given his limited mobility and his complicated med list, or how another one of our CHWs arranged delivery of healthy meals to a patient’s homeless shelter, persisting even when the shelter was reluctant to make arrangements for their storage. CHWs that are truly embedded in neighborhoods have deep knowledge of the places they work because they are the same places that they are from. That’s why public health responses from measles to mental health are supercharged by CHWs.”
Also speaking at the event was Bechara Choucair, M.D., executive vice president and chief health officer at Kaiser Permanente. He served as the White House vaccination coordinator in the midst of the COVID-19 pandemic. “It was so clear that when people had questions about the vaccines and wanted to talk to people they trust to make that decision about getting vaccinated or not, they looked to community health workers,” he said. “There is no doubt in my mind that community health workers are a great community asset that help deliver better health outcomes across populations, and at the same time, strengthen community resilience.”
Choucair said that five years ago Kaiser Permanente started an initiative with community health workers in the Pacific Northwest. “These CHWs worked with our members with high social needs who were at higher risk for higher utilization and poor outcomes, and they help them address some of the root causes of our members’ health problems,” he explained. “This included helping them get access to reliable transportation, stable housing, healthy food, amongst other needs. Our data has shown that the members paired with a community health worker had more primary care visits, had fewer days in the hospitals, and their total cost of care did go down.”
Kaiser Permanente also has learned how important it is to focus on recruitment and training and providing the right infrastructure and the support that community health workers need for that program. “Since that early effort that started years ago, our model now includes different patient populations and has seen benefits for both social and medically complex patients,” he said. “Now we’re planning to take these results and integrate more community health workers into our organization.”
Also speaking at the Common Health Coalition’s event was Simbo Ige, M.D., M.S., M.P.H., Commissioner of the Chicago Department of Public Health.
“We have done many surveys in Chicago, and overwhelmingly, people trust the folks who have shared lived experience, people who understand their daily realities,” she said, going on to describe a program that uses healing arts, with community health workers leading meditation, sound therapy spaces, and yoga to help create spaces for healing using the arts.
““What we found is that communities feel more comfortable in those spaces when these human beings who are drawing them into the conversation are from the communities,” Ige explained. “They are using practices that the community feels connected to, and through these practices, through this bridge-building, communities, feel more comfortable coming into clinical spaces and now are more eager to understand that we’re doing these healing practices for you, but we feel like you might benefit from a therapist, and we feel like you may need to consult with a psychiatrist. And that has just opened up the mental health space in a way that was unprecedented — not just that people are engaging in this healing arts, but that now they are more open to additional services that they need. So this is an example of how trusted messengers can accelerate healing, accelerate access and accelerate trust.”
CHWs can build a connective tissue between many different social services and healthcare and public health organizations, said Aurora GrantWingate, members and partners engagement manager for the National Association of Community Health Workers. “A lot of community health workers are doing this very naturally and sort of informally, just as part of their day-to-day life. That is a huge benefit for healthcare and public health organizations to help fill in some of those gaps in social services, to help patients and healthcare providers focus on their day-to-day jobs.”
Kangovi stressed that there has been plenty of research to show the efficacy of CHW deployment. “What if I told you there was a treatment for loneliness, discrimination, and intergenerational poverty that had been tested in multiple randomized controlled trials, the same way that we would test a new drug or a medical device that had tens of thousands of trial participants across all different conditions, all walks of life, and we were able to show that this treatment improved mental health, improved blood pressure, it improved A1c, it lowered smoking rates. It got people access to primary care, colon cancer screenings, mammograms, and it lowered total hospital days by 34%, saving every taxpayer $2,500 per patient treated annually. Would we try to get people access to that medication? I think we would,” she said. “And that treatment, does exist. It’s empathy delivered in a structured way by community health workers.”
As Medicaid and Medicare start to offer ways that managed care organizations can pay for community health workers and even more funding opportunities start to appear, Kangovi said she worries about how that could impact this workforce 10 years from now. “I think there’s a huge risk that the workforce gets co-opted, both in terms of identity and in terms of the quality of services that they are providing. My worry is that once the billing codes are part of our day-to-day lives, people who don’t really represent the communities that they serve — suburban nurses or EMTs or pharmacy techs — can take a training course and call themselves a community health worker and bill that code to do checklist screening and refer you. Do you have enough food to eat? Here’s a number to a food pantry. Trust doesn’t come without trustworthiness, and that requires some guardrails for who community health workers are. How can we really ensure the quality of services that they provide? Organizations have to be held accountable for hiring the right people, paying them a living wage and having wage transparency, having career ladders, having true person-centered work practices that transfer power to the people who they are serving.”
